Nowadays, it’s really important to understand the meaning of credentialing and what means when a physician is credentialed or have privileges to treat you. If the physician doesn’t have one or both, it can mean treatment options for you are strictly limited.

Unsurprisingly, every patient searches for a competent and appropriately trained physician. Unfortunately, fraud is something to be aware of. For example, in California, two unqualified individuals posed as doctors which led to patient harm.

That’s why patients should know about credentialing – a process, that verifies qualification, training, and practice history of a physician, which protects patients from being duped. It also protects you from those providers who had sanctions levied against their license. To get credentials, physicians should fill out an application and submit it, but prior to that he or she should make sure no little detail is missing. Work history and specialty boards are one of many things that should be carefully checked before submission.

Copies of all documents – residency certificates, medical degrees, etc, – should accompany the application. Physicians should also provide professional references that can prove the competency. A declaration, which confirms that the physician has never been fired from a job for competency issues, is also required. All in all, there is a long list of documents that should be provided in order to start the credentialing process. Among them, there is a confirmation of not being an addict, convinced felon or hasn’t been disciplined for illegal or questionable activity. Then every hospital has a committee that reviews the application and then grants or declines privileges and credentials to provide services in the facility.

Before the committee grants credentials or privileges, all information is thoroughly checked and verified. This makes sense, because too many people make mistakes, embellish or even lie on their applications. For example, the biggest fraud in history is lying about graduation from one of the best Universities and having a Ph.D. The job of credentialing committee is to check up on all the details. In the example above, that person managed to hoodwink all verifies and was picked up much later by accident.

Physicians should also go through the process of -re-credentialing at least every three years, although they can do it more frequently. Re-credentialing is necessary to provide all changed information for verification. This process is almost identical with the credentialing process; however, practitioner’s work history, education, and training aren’t verified. Re-credentialing is necessary to check physician complaints and sanctions, so that they can react on safety and quality issues that arise.

Simply put, credentials are a proof of skills and competence. Verification of all licenses, education, training, insurance, identification and all history related to professional activity doesn’t leave a chance of fraud. It may sound quite simple, but this process is really complicated and time-consuming and physicians have to go through all this to get verification. Those physicians, who understand that this process is necessary, care both about the facility and patients. And patient safety should always be the first priority.

Provider credentialing is not just filling multiple forms; it’s an ongoing, complex process, which is extremely important for every healthcare facility. Without proper credentialing, physician reimbursement for services can be denied, or, at least, delayed. Given its deadlines, many steps and uncertainties, physician credentialing is critical for hospital’s practice.

Put simply, credentialing means verification of your expertise, experience, willingness to provide quality care, and interest. Many professionals describe credentialing as obtaining hospital privileges, as well as enrolling in health plans as a participating physician. Even after submitting multiple forms and documents to different third parties to verify your information don’t think everything is done. Even though health plans and hospitals don’ require a re-hashing of the process, many oblige physicians to submit their updates annually. It means, credentialing process never stops, it consumes hours each year, and especially if you don’t follow it properly.

Although a lot of people now use CAQH and different credentialing software to reduce paperwork, many hospitals still prefer managing everything manually or using electronic databases that can’t be connected to other systems. The process is usually not flawless and a lot of time is spent researching and maintaining credentialing files for physicians.

Not only completing all application takes a lot of time, but hospitals spend even more time to perform the credentialing process. Unless you’re going to work in a cash-only practice and forget about hospital privileges, you should try to find ways to make the credentialing process faster and easier.

Whatever you do, don’t expect that everything will go smoothly. You should start planning months ahead, especially when new physician is joining your staff. Unfortunately, many organizations require the same documents needed for credentialing process at the same time. With that in mind, you should allow enough time for every organization to process their own paperwork. A physician who ignores your request for additional credentialing information can become a financial problem – he/she simply can’t bill for services. Consider trying an initial paycheck or a new start date to successfully gather, submit and sign all documents. Even if you prefer outsourcing credentialing to third parties, you still need a person to pursue the process – somebody who can go to physician’s home to get a copy of the diploma or deliver all documents to the bank to get them notarized.

While initial submission of all applications can be quite time-consuming, it’s important to make sure that somebody maintains all forms because re-credentialing is coming soon. Many hospitals can’t support a lot of credentialing managers, so there are not that many options for them to handle the workflow. The easiest and the cheapest option is to create a spreadsheet of payers, third parties and hospitals that should be constantly updated and have all deadlines and requirements. Or hospitals may assign one of their employees to monitor the credentialing process and take actions to get data gathered and forms signed. Regardless your decision, always monitor the effectiveness of the process to ensure you’re getting your money worth.

Credentials verification organizations, or CVOs, gather and verify necessary information about practitioner’s education, background, experience, training, skills, and competence, just like a traditional medical office in a hospital would. Nowadays, there are over 100 CVOs in the US, and the vast majority of them are certified or accredited by the National Committee for Quality Assurance, or NCQA, or Utilization Review Accreditation Commission, or URAC.

Some of the first CVOs were just agreements between the groups of hospitals in a local community to jointly share available information about applicants. One medical staff office was required to confirm training, education, and residency, gathering references, verify certificates and licenses, etc., and then send information for use in other hospitals. Later on, with the advent of the databank, it was decided to make multiple inquiries for the same doctor acting as an agent for many hospitals. As time passed by, both non-profit and for-profit organization also entered the business.

Don’t confuse CVO with other organizations that just gather, store, and disseminate professional information given by practitioners. There are common applications that can’t be used for the process of verifying all information and those organizations can’t collect additional information needed for the credentialing process and executive committees.
Simply put, CVOs acts as an agent of providers to verify, collect, store and disseminate information about the professional history of the practitioner. Licensing and accrediting organizations don’t require CVOs to be certified or licensed, just like hospitals don’t require to be accredited. CVO seeks out accreditation to assist in marketing activities and distinct one practitioner from another.

A hospital may assign any organization as an agent for gathering and verifying practitioner’s information, provided that the hospital has decided that this information can be collected and verified so that it meets all requirements of a hospital and various accreditation agencies and licensing organizations.

When an organization is certified by URAC or accredited by NCQA, the hospital may accept this accreditation without any evaluations or investigations. If the organization isn’t certified or accredited, the hospital has to conduct an evaluation and investigation of the structure, outcome, and documents of the organization. It can be done either in an internal memorandum or in contact.

URAC and NCQA are the only organizations that are allowed to certify or accredit CVOs. None of the organizations that accredit hospitals (such as DNV, TCJ, and HFAP) can approve or accredit CVOs.

For those hospitals who really want to perform their due diligence, there are some questions that will help start the process. For instance, does the organization have a physical location? Does it maintain liability insurance? Or Does it have articles of incorporation? If you’re satisfied with the answers, you won’t have licensure and accreditation problems that usually appear from complete reliance on data provided by the CVO. If you have established a CVO as a part of the hospital system, it will be considered as a parent organization and its findings can be relieved upon just like it happens with a traditional medical office.

Doctors sometimes have to make life-changing decisions. Patients trust doctors assuming that they have enough knowledge to make these decisions – knowledge gained through proper training and experience. And privileging proves that doctors have the experience and training they claim and can be trusted. It keeps patients safe, and eliminates potential treatment errors. Moreover, if the hospital should have known or knew that their doctor is not qualified enough to treat patients which led to an injured patient, the hospital is liable for giving privileges to that doctor.

Privileging refers to a decision whether or not a physician is allowed to practice within a particular healthcare facility and provide some procedures in a specific clinic. The privileges given to a physician can’t be broader that the activities of a certain hospital. Most of the time, privileges copy the set of individual activities a physician is licensed or qualify to perform. Privileges are always site specific since they require consideration of its characteristics like equipment, site size and capacity, number of medical staff, and other resources to ensure the provision of quality health care.

All physicians who provide services which require certification, licensure, or other credentials are required to have those credentials. All privileged physicians performing services have to have appropriate licensures and exclusion status check.
In order to make the right decision about whether or not to approve an application for clinical privileges, physician’s credentials are analyzed and aligned with:
• Site ability to deliver safe patient care of the activity that should be privileged
• Patient need for the activity that should be privileged
• Assessment of experience, education, training and maintenance of skills necessary for the safe delivery of privileges
• Resources available in the facility to provide or support the activities

In a process of getting privileges, a physician will always go through the credentialing process, since there always should be a thorough examination and verification of his skills, education, training, etc. However, if a physician has credentials it doesn’t necessarily mean he has privileges.

The purpose of the evaluation of each physician is to determine that a new recruit has all qualifications and competencies to be granted specific privileges, or if it’s a current staff member, to determine whether the privileges should be discontinued, continued, or revised. Once the appraisal of individual physicians is done, medical staff will provide recommendation to the Governing body and they will decide whether to grant a particular physician privileges.

Every hospital has to ensure that appropriate hospital departments, patient-care areas and the practitioners are aware of the privileges granted to the practitioner. Hospitals should also inform the physician about the revocation and revision of the privileges. Moreover, there are state and federal law regulations that require hospitals to inform appropriate federal and state authorities, databases, and registries, as well as the National Practitioner Databank about practitioner’s privileges being revoked, limited, or constrained in any way.

Credentialing is a popular term among providers, especially among physicians who, just ten years ago, could simply perform cash only services. In contrast, nowadays patients are demanding that providers accept their insurances for payment. Hence, those who don’t want to lose clients and scare potential patients away should go through the credentialing process.

Getting credentials mean filling out and retrieving multiple applications with insurance companies, then submitting everything to them, and then constantly following up. Even though it may sound simple, many would agree the process is nightmarish as it usually doesn’t go smoothly, and many providers have to submit their applications multiple times, spending time contacting insurance companies and fighting delays and rejections. Moreover, many panels can simply say that they don’t accept people with your specialty or they are full.

While the credentialing process will never become one of your favorite things to do, there is still something you can do to make the credentialing a bit easier.

Create a list

Research all insurance companies and choose those you want to get credentials from. Each company has its own credentialing process, so be prepared to submit different application forms and go through multiple interviews.

Complete the CAHQ

The Council for Affordable Quality Healthcare, or CAHQ, is usually required to complete the credentialing process. Almost all big insurance companies, like Aetna or BCBS, use CAQH applications. Thus, you should get yourself acquainted with the system.

First of all, you can’t simply upload your information on CAQH, you need to be invited there by an insurance company. And if you remember that “chicken or the egg” thing, you can imagine how it feels when you need to submit an application to an insurance company. Once you submit it, you should call them to check if they actually received anything and generated a CAHQ number for you. And then you can go to CAHQ and complete the application that you have already sent to the insurance company, which is waiting for the complete application to arrive.

Never submit CAHQ applications on paper

Even though you can choose to either submit an online application or send it on paper, never choose to send papers. First of all, their application is over 50 pages long. And second of all, when you send your application on paper, CAQH hires a data entry person to transfer your data. And if you think it takes a lot of time…they just never do it. Many physicians have submitted their applications on paper and CAHQ simply lost them. And if you call to CAHQ, they will also ask you to submit the application online.

Devote around 10 hours for each insurance company you want to get credentials from

Don’t expect that getting credentials will only take ten minutes of filling out the application. Usually, you need to spend 10 hours of labor for every insurance company. It includes getting and filling out forms and applications, organizing documentations, and checking the process of credentialing.

Credentialing process usually mean that a hospital aims to optimize the utility of their crucial recourses – providers – and ensure highest quality patient care possible. The concept is quite old and slowly getting easier, thus more and more hospitals try to perform a thorough credentialing process and creating new quality standards.

Professionals determine credentialing as the process of collecting, verifying and evaluating qualifications and skills of healthcare providers who want to provide patient care services in a certain healthcare facility. Each hospital has its own set of standards and requirements that their providers have to meet. Credentials mean evidence of training, education, licensure, skills, experience and other qualifications.

There is also a process called privileging that accompanies credentialing. Privileging means a process by which healthcare organizations allow practitioners to perform a certain set of services related to their specialty, based on thorough evaluation of their credentials. Credentialing and privileging ensure medical quality; they help assess initial qualification and prove competence.

Verifying quality care

The importance of credentialing can’t be underestimated and hospitals have to credential their providers to ensure quality care. It’s vital to maintain the high standards of medical care, thus regular verification of qualification and re-credentialing ensure patient safety, provision of quality health services and reduction of possible medical errors.

Hospitals are expected to provide quality care through accurate diagnoses and proper treatment of their patients who come to get the services. Medical providers are the ones who deliver these services and their level of competence and knowledge determines if the patient receives appropriate care.

The credentialing process also ensures that hospitals act according to current laws, state and federal requirements and standards of other certifying organizations that relate to operation of hospitals with regard to the recruitment of its practitioners. Credentialing helps prevent the hiring of a candidate with fraudulent training and degrees to the hospital. After getting credentials, privileging process ensures that practitioners are allowed to perform a certain set of procedures under supervision at the hospital.

Basics of the credentialing process

Professionals believe it’s better if every hospital develops its own standards and documents of this process, thus it’s impossible to find a guide with all steps that will describe norms and procedures of the process. However, there are many similarities in processes of different hospitals; they mainly differ by specific characteristics of each facility, such as recourses, patients served, etc.

The only way to determine the qualifications of medical providers is to get information about their education, training, and licensure, and to review their data in details. The methods that hospitals use to accomplish this difficult task should become routine as the medical staff becomes familiar with them. The hospital has to be sure that its patients are treated properly and that it hires only qualified practitioner, who would perform certain services to the patients.

As a physician, you already know how important the credentialing process and privileging is. These are two aspects that ensure patient safety and high-quality service, but do you know how to apply for it?

Step one – collecting necessary documents

All physicians work hard to become who they are and credentialing (a complicated process of confirming the qualifications of the practitioner) is the most important part of your ability to perform quality services to your patients. Credentialing simply means the verification process that confirms that you, as a physician, have all qualifications, credentials and background for membership in a healthcare organization (such as a hospital).

The credentialing process includes the confirmation of all professional degrees, licensures, clinical training, training certificates, residence certificates, continuing education credits and many more. All these documents are needed to confirm whether or not you meet the latest standards of practice and regulations set by each institution.

Unfortunately, there is no centralized credentialing process, so it can get quite complicated and time- and money consuming. You have to create different submissions for every entity, have to keep off the records and make sure that everything is error-free.

Step two -applying for privileges

When you’re done with credentialing, it’s a perfect time to apply for privileges. It’s a process that grants you with an authorization to provide specific services or treatments at a certain healthcare facility. Privileging can be divided into three main categories:
• Admitting privilege that allows you to admit patients to the hospital
• Courtesy privilege that allows you occasionally to admit and treat patients at the hospital
• Surgical privilege that allows you to operate room surgeries

This is an important step in physician credentialing since it ensures the healthcare facility that you have the experience, skills and competencies necessary for the services you’re going to provide. Once the privilege is approved, you can conduct certain services in a certain facility. For example, a doctor in private practice may want to apply for privileges to perform surgeries, and can even get privileges from more than one facility. Moreover, hospitals are also obliged to answer regulatory entities like Accreditation of Healthcare Organization or The Joint Commission on Accreditation to ensure all physicians are properly privileged at the facility.

Record-keeping is an important part of successful credentialing process

Just as credentialing, the privileging process is long and complex. You will have to provide a lot of details, prove your education, competency, fellowships, residence, licensure, insurance and many more – and get ready to different interviews with the committee and a board of directors: that is an essential part of any investigation process. Both credentialing and privileging are documented, formal procedures that require adherence to every rule and regulation for granting clinical privileges and admission. This means they are the key parts of delivering patients the highest standard of care.

The Affordable Care Act, or Obamacare, will reduce prices for health coverage making it accessible for millions of Americans. Almost 60 million Americans live without insurance, and the law addresses issues concerning inequalities in affordability of health care services, increase access to affordable, quality health coverage, invest in wellness, and give people control over their health care.

According to researchers, there are higher rates of disability, mortality and chronic disease in rural areas. For that reason, the Affordable Health Care Act will transform the insurance industry to improve the health of rural Americans.

Health Insurance Marketplace and rural coverage

At the beginning of 2014, almost 8 million rural Americans under age 65 got new opportunities to get affordable health care through the Affordable Care Act. Just think of the numbers:
• Almost 20% of uninsured Americans live in rural areas
• The vast majority of rural Americans lack proper health care compared to urban Americans
• Rural Americans usually have lower income level, thus subsidized insurance coverage through Marketplaces is necessary
• the Health Insurance Marketplaces should increase competition in rural areas – especially in those states where one insurance company dominates more than a half of the insurance market
• Residents of those states that are expanding Medicaid will get affordable coverage
The Marketplace will lower costs due to increased competition. It will influence rural areas the most, since at least one out of every five residents there faces medical debts and families have to cover almost 50% of the health care payments out-of-pocket.

The Affordable Care Act for Rural Americans

Uninsured Americans from rural areas can use the Marketplace to compare different insurances based on benefits, quality, price, and other factors knowing all premiums and cost-sharing amounts, which should help them pick the perfect health insurance plan that will fit their needs. Each insurance plan should at least cover all essential health benefits, such as emergency and inpatient services, prescription of drugs, behavioral health treatment, and pediatric care.

New coverage options with insurance benefits are already there for rural Americans:
• More than 30 million Americans now can expand preventive services without cost sharing. Among these services, there are blood pressure screenings, well-child visits, mammograms and pap tests for women and flu shots for adults and children
• Over 11 million disabled rural Americas who get coverage from Medicare now also can access different preventive services without cost sharing, such as colorectal cancer and diabetes screening, prevention plans, bone mass measurements, and many others
• More than 600,000 rural Americans below 26 now are covered under individually purchased plans or their parent’s employer-sponsored plan
• Private insurance policies can’t have lifetime limits anymore, and annual limits should be more than $2,000,000.
• Americans under age 19 cannot be denied coverage due to a pre-existing condition

Insurances won’t have to be cheap, but they certainly will be less expensive and you don’t have to pay unexpected costs out of the pocket as if you did without insurance. There are also tax breaks for families with low incomes, which help pay for their insurance.

To practice medicine, physicians have to be licensed by the state in which they’re going to work. However, licenses don’t guarantee that doctor has qualifications to practice a specific specialty, such as surgery or dermatology. One of the best ways to find out about doctor’s qualifications is to know if he/she is Board certified and actively participates in activities to learn about the latest advances in patient care and medicine.

Board Certified physicians voluntarily meet requirements beyond licensing. These physicians show the expertise by obtaining Board Certification through the member Boards that all are part of the American Board of Medical Specialties or AMBS. Before a physician can be Board Certified, he/she has to complete:
• a training leading to a DO or an MD degree from a medical school
• four years of education in a university or college
• five years of experience in a residency program

In the past, boards granted physicians with lifetime certificates, so once they were certified, they got it for life. However, nowadays physicians have time-limited certificates and require frequent recertification. The vast majority of boards require recertification after 5 years with some exceptions. Hospital requirements for certification usually vary, which is based on physician availability. There are areas with an abundance of physicians, thus hospitals require thorough verification of qualification and skill, but in underserved areas, hospitals may not ask for a board certification.

When certification is necessary, physicians should keep track on expiration dates of their certificates. Besides, hospitals’ bylaws should clearly define the requirements for board certification and develop a process that will verify the certification. Sometimes, the medical staff requires the certification within a given timeframe or on the appointment, which means that physicians should keep track of their documents and assure they meet the standards. Hospitals usually send reminder letters prior to the expiration date of a current certificate. Whether recommendations are applied, they should be fair and consistent.

Board certification can be verified by collecting information from the board. There are also more convenient ways: board certification for ABMS is verified using the CertiFacts website, and many other certifications can be verified online.

However, hospital’s governing body has to make sure that under no circumstances clinical privileges in the facility depend on only upon certification, membership or fellowship in a society or a specialty body. In other words, hospitals have to perform a thorough check of background information and qualifications of physicians even if they have a certification. A hospital can require a board certification when thinking of a DO/MD for membership. However, they should not rely on the fact that a DO/MD is or isn’t board certified in making a final decision in membership. In addition to the board certification, hospitals should also verify other criteria such as character, training, judgment, and competence. After a thorough evaluation of all criteria, if these criteria are met except for certification, the hospital can decide to select or not to select a physician to the staff.

Negligence means a guilty conduct because it falls short of what a person would do to protect another person from a preventable harm or risk. If a healthcare facility could possibly foresee that a physician isn’t qualified and the physician injures a patient, the hospital is separately liable for the negligent privileging and credentialing of the physician. Healthcare facilities are legally responsible under multiple theories. Some of them have been held responsible for the failure of the thoroughly screen a physician through the processes of credentialing and privileging, or for negligent credentialing. Negligent credentialing is recognized by at least 28 states. However, there are other theories under which hospitals are held responsible.

Liability theories

There are states where negligent credentialing falls under the corporate negligence doctrine or corporate liability. The main idea of the theory is that when patients enter a hospital they do so with a reasonable assumption that the hospital will try to cure them. Hospitals have the duty to make a lot of efforts to monitor and evaluate the treatment and care administrated and prescribed by the providers practicing in the facility. Hospitals are also responsible for granting privileges only to professional, competent physicians.

The governing body is responsible for making final decisions in credentialing and privileging matters. Although the Board Certification can also be partially responsible, since they verify physician’s information regarding his/her experience and training, the ultimate decision-making power belongs to the governing body.

There are two doctrines that make hospitals responsible for hiring unqualified providers. Patients can’t choose the practitioners, so it’s a healthcare facility who should carefully decide who can be a member of the organization and who can’t.

Elements of Negligence

Patients should understand that the fact a hospital didn’t credential a physician adequately doesn’t mean that the healthcare facility was negligent. For instance, if the hospital can’t verify medical licenses for a competent and qualified physician within the requirements of the credentialing standards, this shouldn’t be seen as negligence.

In order to establish negligence, one should analyze specific elements. For example, there should be a duty to exercise due care, and duty must be breached. There is also has to be an injury, and the breach of duty should be a reason of the injury. Besides, the patient bringing the charges has to prove that the injury caused him/her compensable damages.

As it was illustrated in a previous example, let’s imagine that a physician injured a patient and it was proved that the injury was a result of negligence. If it was proved that the healthcare facility failed to verify the experience, qualification, and competence on initial appointment, and if it would have found that physician’s licensure was suspended, only then it can be assumed that proper credentialing wouldn’t lead to the injury. In this example, it’s pretty easy to conclude that the breach of duty to properly credential that physician could have led to the injury of a patient.